New vs Established Patient CPT Codes for Office Visits
If you are searching for an established patient CPT code, a new patient visit CPT code, cpt code for an established patient office visit, cpt code for a new patient office visit, or new versus established patient, the main question is usually the same: Is this patient new or established, and which office visit code range should be used? For office or other outpatient E/M visits, the common code ranges are 99202–99205 for new patients and 99211–99215 for established patients. The final code level is then chosen based on the visit itself, not only on patient status.
What is a new patient?
A new patient is a patient who has not received professional services within the past 3 years from the physician or other qualified health care professional, or from another physician/QHP of the exact same specialty and subspecialty in the same group practice. In easy words, the patient is usually new if they have not seen that same specialty in that same group during the last 3 years.
What is an established patient?
An established patient is a patient who has received professional services within the past 3 years from that physician/QHP, or from another physician/QHP of the exact same specialty and subspecialty in the same group practice. In simple language, an established patient is already known to that same specialty in that same group.
When is a patient considered new?
A patient is considered new when there has been no professional service in the last 3 years from the same physician, or from the same specialty and subspecialty in the same group practice. This is the rule behind searches, such as when a patient is considered a new patient, the definition of a new patient, and how to define a new patient.
When is a patient considered established?
A patient is considered established when they were seen within the last 3 years by that physician/QHP, or by another physician/QHP of the same specialty and subspecialty in the same group. This covers the intent behind searches like define established patient, established patient meaning, existing patient, and what does established patient mean.
CPT code for a new patient office visit
For an office or other outpatient new patient visit, the standard E/M code family is 99202, 99203, 99204, and 99205. CMS also notes that 99201 was deleted, so the current office/outpatient new-patient coding starts at 99202.
CPT code for established patient office visit
For an office or other outpatient established patient visit, the standard E/M code family is 99211, 99212, 99213, 99214, and 99215. These are the common code options people mean when they search for established pt CPT code, cpt code for established patient office visit, or what is an established patient visit.
New patient code vs established patient code: what is the difference?
The first difference is patient status. The second difference is the visit level. A new-patient visit is chosen from the new-patient code family, and an established-patient visit is chosen from the established-patient code family. After that, the level is selected based on the current E/M rules, which use medical decision making and, when applicable, total time on the date of the encounter.
New vs established patient: simple examples
A patient who saw the same family medicine doctor 10 months ago and returns for another office visit is usually an established patient. A patient who has not seen that doctor, or the same specialty in that group, within the last 3 years is usually a new patient. If a patient saw one cardiologist in a group and now sees another cardiologist in the same specialty/subspecialty in the same group within 3 years, that patient is generally still established.
A patient may still be new to one specialty even if they have already visited a different specialty in the same multispecialty group. For example, a patient seen by dermatology before may still be new to endocrinology if the specialty is different. The key rule is not only the group name. The key rule is that the same specialty and subspecialty in the same group.
What if the patient sees a covering doctor?
If one physician or qualified health care professional is covering for another, the encounter is classified the way it would have been classified for the original clinician. In easy words, coverage alone usually does not turn an established patient into a new patient.
What is a specialty office visit CPT code?
There is not one single CPT code just because the visit happens in a specialist’s office. In most cases, the office visit is still reported from the normal office/outpatient E/M families: 99202–99205 for a new patient and 99211–99215 for an established patient, with the exact level based on the visit. For Medicare, CMS says office/outpatient consultation codes are not recognized for payment in that setting, and clinicians should bill the appropriate new or established office/outpatient visit code instead.
How to decide whether the patient is new or established
Ask these questions in order:
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Has the patient received professional services in the last 3 years?
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Was it from the same physician or QHP, or the same specialty and subspecialty in the same group?
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If yes, the patient is usually established. If no, the patient is usually new.
Common mistakes in new patient coding
A common mistake is thinking a patient is new just because they are new to a specific location or new to one individual doctor, even though they were already seen by the same specialty in the same group within the last 3 years. Another common mistake is looking for one special specialty office visit code when the right answer is usually the normal office/outpatient E/M code family. Another easy mistake is using 99201, even though that code was deleted.
Simple Definitions: New Patient vs Established Patient
Established patient meaning: a patient who received professional services within the last 3 years from that physician/QHP or the same specialty/subspecialty in the same group.
New patient meaning: a patient who did not receive professional services within the last 3 years from that physician/QHP or the same specialty/subspecialty in the same group.
Existing patient meaning: this is usually used informally to mean an established patient, but coding decisions should follow the official new vs established rule.
FAQ
What is the CPT code for a new patient office visit?
The common office/outpatient new-patient CPT code family is 99202–99205.
What is the CPT code for an established patient office visit?
The common office/outpatient established-patient CPT code family is 99211–99215.
When is a patient considered a new patient?
A patient is considered new when they have not received professional services from the same physician/QHP or within the same specialty and subspecialty in the same group in the last 3 years.
What does an established patient mean?
It means the patient has already received professional services from that physician/QHP within the last 3 years, or from the same specialty and subspecialty within the same group.
Can a patient be new to one specialty and established in another?
Yes. In a multispecialty group, a patient may be established with one specialty and still be new to a different specialty.
Is there one CPT code for a specialty office visit?
No. Usually, you select the correct office/outpatient E/M code based on whether the patient is new or established and on the visit level. For Medicare office/outpatient visits, CMS directs clinicians to use the appropriate new or established office/outpatient visit code rather than office consultation codes.
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